Provider Demographics
NPI:1497590095
Name:BUSHYHEAD, MIKAH TAYLOR
Entity type:Individual
Prefix:
First Name:MIKAH
Middle Name:TAYLOR
Last Name:BUSHYHEAD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 HINTON BLVD
Mailing Address - Street 2:
Mailing Address - City:MANNFORD
Mailing Address - State:OK
Mailing Address - Zip Code:74044-9500
Mailing Address - Country:US
Mailing Address - Phone:918-807-2025
Mailing Address - Fax:
Practice Address - Street 1:614 S MAIN ST
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-4059
Practice Address - Country:US
Practice Address - Phone:405-600-2347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-26
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1129056106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician